Case Study – Fluid Volume Excess
Ms Water is an 82 y/o female admitted with cirrhosis and renal failure. The provider states she has fluid volume excess. Her history consists of Type II diabetes and hypertension.
1. What nursing assessment would you perform to detect Fluid Volume Excess and why? assessing for s/s of efc volume excess changes in blood pressure,pulse force and jugular vein distention. pulse force will be full and bounding , because of the expanded intravascular volume pulse is not easily obliterated. Increased volume causes distended neck veins ( jugular venous distention) and increased blood pressure
2. Upon assessment you note that Ms Water has SOB and orthopnea. Why would she have this and what nursing interventions can you do to help decrease this? What further assessments would you need to perform?
Increased hydrostatic pressure in pulmonary vessels causes more fluids into the alveoli, resulting in pulmonary congestion and edema; causing shortness of breath and orthopena and bilateral crackles.
Lewis p 322
Interventions: restrict fluids and lower Na intake in diet. Monitor I & O.
3. Upon assessing the lungs you note bilateral crackles – why would she have this and what further nursing assessments and interventions would you do for this? Explain your rationale for the interventions.
Rationales for interventions:
Fluid restrictions and Na restrictions may reduce fluid volume.
Gulanick p.76
4. Upon further assessment you note she has distended neck veins and 3+ pitting edema to her lower extremities – why would he have this in FVE and what nursing interventions would you do for this? Explain your rationale for the interventions.
Neck veins are distended due to excess fluid in the blood. Edema evidenced by pitting is due to cells swollen by excess fluid.
Interventions: monitor vital signs. elevate extremities. Monitor skin condition.
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The provider orders the following: Explain the rationale for these orders and nursing assessments when performing these tasks. What is the rationale for the assessment? What findings would you feel necessary to report to the provider? I&O-identifies sources of excessive intake, decreased output
daily weight-measures volume status
fluid restriction of 1000mL/day-excessive fluids will make pt's condition worse
2gram Na diet-helps decrease blood pressure and fluid retention
pt in semifowler's position-helps relieve shortness of breath, keeps airway patent
- I&O
- Daily weight
- Fluid restriction of 1000mL daily
- 2gram Na+ diet
- Patient in semi-fowler’s position
The provider orders a chem. Panel. The K+ comes back 2.8. What is the significance of this? K+ of 2.8 indicates low potassium level.It determines the body's ability to keep blood pressure under control and maintain proper fluid level in body. I would expect the dr. to order oxygen at 2L/min, cardiac monitoring, and bedrest
What are s/s of hypokalemia? fatigue, muscle weakness, HTN, nausea and vomiting, hyperglycemia
Two hours later you go into the room and notice that the IV has infused incorrectly because of IV pump malfunction. You immediately notify the provider. What other nursing assessments would you perform and why?
The provider orders a Chem 7. The K+ comes back 6.2. What is the significance of this? Pt's potassium level is too high(hyperkalemia). Pt is taking in too much potassium and not eliminating it properly due to renal failure.
What would you expect to see on her EKG? What cardiac implications does hyperkalemia have? would expect to see wide, flat P wave, prolonged PR interval, decreased R wave amplitude, widened QRS,a depressed ST segment, and a tall,peaked T wave. Cardiac depolarization is decreased and repolarization is more rapid. Ventricular fibrillation or cardiac standstill may occur.
The provider order 1unit regular insulin per 1mLof D5W fluid to infuse at 100ml/hr. Why would this be ordered? insulin promotes potassium shift from blood to cells
12 hours later the patient’s K+ is 5.3. The provider orders a diet restriction of potassium rich foods. How would the nurse counsel this patient regarding the diet restriction? Who could help you with this education?
Case Study – Fluid Volume Excess
Ms Water is an 82 y/o female admitted with cirrhosis and renal failure. The provider states she has fluid volume excess. Her history consists of Type II diabetes and hypertension.
1. What nursing assessment would you perform to detect Fluid Volume Excess and why? assessing for s/s of efc volume excess changes in blood pressure,pulse force and jugular vein distention. pulse force will be full and bounding , because of the expanded intravascular volume pulse is not easily obliterated. Increased volume causes distended neck veins ( jugular venous distention) and increased blood pressure
2. Upon assessment you note that Ms Water has SOB and orthopnea. Why would she have this and what nursing interventions can you do to help decrease this? What further assessments would you need to perform?
Increased hydrostatic pressure in pulmonary vessels causes more fluids into the alveoli, resulting in pulmonary congestion and edema; causing shortness of breath and orthopena and bilateral crackles.
Lewis p 322
Interventions: restrict fluids and lower Na intake in diet. Monitor I & O.
3. Upon assessing the lungs you note bilateral crackles – why would she have this and what further nursing assessments and interventions would you do for this? Explain your rationale for the interventions.
Rationales for interventions:
Fluid restrictions and Na restrictions may reduce fluid volume.
Gulanick p.76
4. Upon further assessment you note she has distended neck veins and 3+ pitting edema to her lower extremities – why would he have this in FVE and what nursing interventions would you do for this? Explain your rationale for the interventions.
Neck veins are distended due to excess fluid in the blood. Edema evidenced by pitting is due to cells swollen by excess fluid.
Interventions: monitor vital signs. elevate extremities. Monitor skin condition.
daily weight-measures volume status
fluid restriction of 1000mL/day-excessive fluids will make pt's condition worse
2gram Na diet-helps decrease blood pressure and fluid retention
pt in semifowler's position-helps relieve shortness of breath, keeps airway patent
- I&O
- Daily weight
- Fluid restriction of 1000mL daily
- 2gram Na+ diet
- Patient in semi-fowler’s position